Community Prevention & Harm Reduction Request Form
Thank you for helping make our community safer.
Please fill out the brief online form to request prevention and or harm reduction items. This confidential process includes the option of: 1. a contactless delivery within Jefferson County or 2. pick up from our Watertown offices on Polk Street. We are a community coalition comprised of members who live / work in Jefferson County, NY. We come from all sectors in the community with a common goal in mind: to create a safer, healthier, and drug-free community for our youth. We are mostly federally funded by a Drug-Free Communities grant (Alliance for a Better Communities), a Strategic Prevention Framework grant (The Youth Alliance / Healthy Jefferson) and by New York State OASAS (Anchor Recovery Center providing NARCAN). Our partnership recognizes our local problems require local solutions.
Name
First Name
Last Name
I would like to arrange to:
Pick Up Alliance for Better Communtiies office in Watertown, NY.
Have it delivered to me, it is not time sensitive.
Please contact me so we can discuss best option.
How would you like confirmation this request was received? YOU MUST PROVIDE ONE FORM OF CONTACT AND PROVIDE IT BELOW FOR CONFIRMATION PURPOSES.
Home phone provided
Cell provided for confirmation text message
Email address provided
Home Phone Number (not mandatory unless a home phone call is preference for confirmation).
Please enter a valid phone number.
Cellular Phone Number (not mandatory unless a text to a cell is the preference for confirmation).
Please enter a valid phone number.
Email (not mandatory unless you are receiving confirmation via email or you have requested additional information below.)
example@example.com
Address (not mandatory unless you want us to deliver to a particular address in Jefferson County). Delivery may take longer and if needed quickly we suggest an anonymous pick up at our office in Watertown.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I would like to request the following items at no cost:
Medication Lock Box (This lock box can fit basic pill bottles and medicine cabinet items).
Cannabis / Medication Lock Box (This is a larger lock bock for items such as marijuana, edibles, drug use items that can be harmful to children, youth and pets).
Deterra Safe Medication Disposal Bags (These are bags for your home to safely dispose of medications).
Tamper Tape (This is tape to use so parents are aware if items such as alcohol have been opened).
Fentanyl Testing Strips (These are testing strips for the deadly drug Fentanyl).
BAC Testers (These are disposable Blood Alcohol Testing tools).
"Date Rape" Detection / Protection Items (This can include drink slipping deterrents and testing cards for a persons drink to ensure there are no drugs added).
I would like to schedule Narcan training and receive a Narcan kit.
Yes, I have provided contact information to make arrangements.
Not at this time.
I have provided contact information to schedule a group.
Additional or group needs. Please ensure you have provided a valid email address:
Submit
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